Failure to Administer Medication at Prescribed Times
Penalty
Summary
The facility failed to ensure the accurate and timely administration of medication for one resident who had an order for gabapentin to be given four times daily at specific scheduled times. The resident, who had diagnoses including type 2 diabetes with neuropathy and mild neurocognitive disorder but was cognitively intact and their own decision maker, had a physician order specifying gabapentin administration at 7:30 AM, 12:00 PM, 4:00 PM, and 8:30 PM, with instructions not to give the medication early. Review of the Medication Administration Record (MAR) revealed that on multiple occasions, the medication was administered outside the one-hour window allowed by facility policy, including doses given significantly late in both the morning and evening. Interviews with the resident's family representative, the Director of Nursing (DON), and the facility's President of Success confirmed concerns about the late administration of gabapentin and verified that the medication was not given at the prescribed times on several dates. The DON acknowledged that the specific administration times were requested by the family and ordered by the physician, and confirmed that the facility policy allows a one-hour window for administration unless otherwise specified. Despite this, the medication was not administered within the required timeframe, resulting in a failure to meet the resident's pharmaceutical needs as ordered.